197607012-11-19-2024-31-AS-EMIR-DDET2P-20250130132101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607012
Report Date: 11/19/2024
Date Signed: 11/19/2024 03:40:14 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2024 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20240125095336

FACILITY NAME:	JBM RESIDENCE HOME, INC.		FACILITY NUMBER:	197607012
ADMINISTRATOR:	JOSEPHINE B. MIRANDA		FACILITY TYPE:	740
ADDRESS:	3205 ARIOUS WAY		TELEPHONE:	(661) 522-1968
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 6	DATE:	11/19/2024
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Josephine B. Miranda		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staffing insufficient to meet the needs of residents.

INVESTIGATION FINDINGS:

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On 11/19/24 Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conducted a subsequent complaint visit to continue investigation and deliver the determination on the above mentioned allegation. Upon arrival, LPA was greeted by staff #6 (S6) and was granted access. LPA met with Administrator, Josephine Miranda and LPA explained the purpose of todays visit. Entrance interview conducted.

On 01/31/24 LPA Rios conducted an initial visit. A physical plant inspection was conducted. From 10:12 a.m. to 11:40 a.m. LPA reviewed six (6) resident records and obtained copies of pertinent information. From approximately 12:12 p.m. to 1:30 p.m. LPA interviewed the administrator, S1, a family member of resident #3 (R3) and residents at the facility. At approximately 2:09 p.m. LPA reviewed seven (7) staff records. On 10/16/24 on a subsequent visit, the administrator did not make themselves available or got in contact with LPA at the time of visit. On todays visit LPA reviewed and obtained copies of the Personnel Report (LIC500) and resident roster. LPA also reviewed six (6) resident files and six (6) staff records. (Cont. to LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 31-AS-20240125095336

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JBM RESIDENCE HOME, INC.	FACILITY NUMBER: 197607012
	VISIT DATE: 11/19/2024

NARRATIVE

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Allegation: Staffing insufficient to meet the needs of residents. It is alleged, the administrator only has one (1) caregiver for 5 to 6 residents. On 1/24/24 LPA's review of resident roster revealed prior to LPA's initial visit six (6) residents had been at the facility. At time of the initial visit the facility census was five (5) because one resident had passed away. Three (3) residents were physically at the facility and two (2) were hospitalized. LPAs interview on 1/24/24 with staff #1 (S1) revealed that they had assisted up to (5) five residents with the help of S2. S1 stated they now assist three (3) residents and administrator helps. On 1/24/24 LPA attempted to interview three (3) residents, two (2) did not respond to questioning. LPAs interview with resident #2 (R2) revealed they have no issues or concerns with the assistance provided. On 1/24/24 administrator presented LPA with LIC 500 from January 2023. Administrator noted they had not updated personnel report. According to the administrator at time of visit the facility had one reliever (on-call), staff #4 (S4) and one full time staff, S1. A second reliever staff #5 (S5) was no longer able to work at the facility. Facility had lost one full time caregiver, staff #3(S3) on 12/23/23. S1 took over the schedule and according to administrator another caregiver, staff #2(S2) had stopped working a week prior to initial visit. According to administrator reliever and herself were working with S1 until she could hire a second staff. On 01/24/24 LPA attempted to contact previous staff and reliever. LPA left voicemail for return call for S3 and S5. Administrator could not provide contact information for S2. S4's telephone was disconnected. Review of five (5) out of seven (7) staff records on 01/24/24 revealed S1 and S4 did not have complete training. Review of S1 and staff #6 (S6) record on 11/19/24 revealed S1 has completed training since initial visit and S6 is missing orientation training. Review of six (6) resident records revealed they required assistance with incontinent care and toileting. All residents were non ambulatory of which one (1) resident was temporarily bedridden and four (4) had a diagnoses of dementia. Review of six (6) resident records on 1/24/24 revealed resident #2 (R2) did not have a pre appraisal or resident appraisal conducted. Based on resident records and review of LIC500, this allegation is deemed Substantiated at this time.

Deficiencies cited on LIC 9099 D. Appeal Rights provided. Exit Interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240125095336

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JBM RESIDENCE HOME, INC.	FACILITY NUMBER: 197607012
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/22/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has hired a second staff and S1 has orientation and ongoing training on file as of todays visit. Licensee will submitt required orientation training for new staff, S6 and an updated LIC500.
	8 9 10 11 12 13 14	Based on the LPA's record review and interviews, the licensee did not comply with the section cited above in 2 staff not having on going training on file and S1 and administrator who was also working other shifts providing care for 5 residents which posed an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC9099 (FAS) - (06/04)

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